Clinical

Restoration of endodontically
treated teeth
There have been many recent advances in the methods available for restoring endodontically
treated teeth. This article provides a practical guide to the restoration of endodontically treated
teeth based on the amount of sound tooth structure remaining

Restoration choice

The choice of restoration for an

endodontically treated tooth is dependent
on the amount of coronal tooth tissue
left. In fact, this single most important
factor will dictate the retention of the
restoration and the fracture susceptibility
of the tooth. The suggestion from existing
literature is there is a relationship between
the fracture resistance of endodontically
treated teeth and the residual amount of
tooth structure. Hence, the life expectancy
of endodontically treated teeth may not
necessarily be increased by the choice of
Massimo Giovarruscio, Specialist
Endodontic Clinical Teacher,
Kings College London Dental
Institute, London
Email: giovarruscio@me.com

330 

restoration but rather by the amount of

tooth structure preserved. Anterior and
posterior endodontically treated teeth
present differing restorative demands.
Anterior teeth may be less prone to
fracture but compared with posterior
teeth, aesthetic is a major consideration.

Anterior teeth

Composite resin restoration

In anterior teeth where there has been little
previous restoration, a combination of
composite resin placed over a base of glass
ionomer cement may suffice. Composite
resin is the most appropriate material for
restoring the access cavity given its physical
properties, high quality surface finish and
the good seal achieved with bonding.
If the tooth is discoloured, bleaching
techniques may be used, particularly if the
discolouration is mild (Figures 1a and b).
Internal and external bleaching techniques
may be applied.

Ceramic or composite resin

veneers
If the coronal tooth tissue loss is less than
one-third, the palatal aspect of the tooth
is to be preserved but if it is impossible
to obtain a good aesthetic result using
a direct restoration, then a ceramic or
composite resin veneer may be placed.
Veneers normally cover the entire labial
surface of the tooth, including the incisal
edge and through to the proximal contacts
(Figures 2af). Ceramic or composite
resin veneers are seldom recommended
for endodontically treated anterior teeth

as it is not easy to incorporate the access

cavity within such restorations.

Metal-ceramic crowns
Among non-adhesive techniques, metalceramic crowns have become the most
commonly prescribed indirect restoration
for endodontically treated anterior teeth.
A reduction of the labial surface of
approximately 1.82mm is necessary. The
extent of tooth reduction may compromise
the strength of the remaining tooth tissue,
so caution should be exercised before
prescribing such a restoration. Far from
preserving residual tooth structure, it
may actually promote its loss. In general,
crowning of anterior teeth is indicated if
the amount of tooth structure left is not
sufficient for a direct restoration and for
aesthetic reasons.

All-ceramic crowns
All-ceramic crowns are more fragile than
metal-ceramic crowns. However, the
advantages of all-ceramic crowns are:
n Labial tooth reduction required is, again,
less than that for metal-ceramic crowns
n Absence of a metallic substructure
allows a better aesthetic result, especially
in areas close to the soft tissues.
After root canal the tooth could
become darker (discoloured) due
to the endodontic procedures and for
this sometimes an internal bleaching is
required to match a better colour. As
abutments for bridges, all-ceramic crowns
are only indicated for three-unit bridges
in cases of high aesthetic requirement; in
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he completion of root canal

treatment does not signal the
end of patient management.
The endodontically treated
tooth has to be restored to both form
and function. In addition, there is now a
greater appreciation that coronal leakage
may cause failure. Therefore, the quality
of the coronal restoration has an influence
on treatment outcome. The availability
of adhesive techniques has expanded
treatment modalities. Amalgam cores and
cast metal posts are being replaced by
adhesive techniques and fibre posts; allceramic and composite resin crowns are
chosen for better aesthetics.

Clinical
such cases, a zirconium construction is
indicated (Figure 3).

Resin crowns
Resin crowns require less tooth tissue
reduction (typically 0.81mm) and the
aesthetics is good. However, they are
just as expensive as metal-ceramic and
all-ceramic crowns, and yet they are not
as durable. They may be considered as
interim rather than final restorations.

Posterior teeth

Amalgam restoration
A conventional amalgam restoration,
including interproximal extension but no
cuspal coverage, is largely contraindicated
because of the high risk of cuspal or root
fracture (Hansen et al, 1990). Amalgam
restorations providing a minimum of
2mm of cuspal coverage was regarded as
particularly suitable for mandibular molars
but aesthetic concerns have diminished its
popularity.

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Composite resin restoration

In general, composite resin restorations
cannot be regarded as definitive
restorations in posterior teeth except in
cases where there has been very limited
loss of tooth structure; for example, small
interproximal boxes and little or no cuspal
overlay (Figure4). There is no consensus on
the minimum thickness of composite resin
required to protect cusps from fracture.
Coverage of all cusps with less than 2.5mm
thickness of composite resin has been
suggested. In most cases, the loss of tooth
structure caused by proximal caries and the
resultant large and deep access cavity makes
the placement, shaping and finishing of a
direct composite resin restoration difficult to
perform. The problem may be compounded
if cuspal coverage has to be provided. In
such cases, a direct composite filling may
result in a poor reconstruction of the coronal
anatomy and deficient contact points will not
be capable of preventing food impaction.

Composite resin and ceramic

onlays/crowns
Such restorations are contraindicated in
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Figure 1. (a): A discoloured maxillary left central incisor due to trauma following
internal bleaching; (b): an aesthetically improved result was obtained without the
need for a cosmetic restoration
teeth that are meant as bridge abutments.
An initial direct, self-curing composite
resin core build-up is generally indicated;
the colour should be a shade different from
that of dentine, in order to differentiate the
composite from the dentine. This core will
serve as a guide in designing a cavity for
optimal material thickness. Posts are not
normally used for retention of the core.
The onlay preparation is similar to that
used for vital teeth. A minimum thickness
of 1.52mm is required for the composite
resin or ceramic material.
The margins are normally a 90
shoulder finish, and the internal line
angles of the cavity are rounded. Proximal
boxes should only be extended above the
contact points and internal walls should be

divergent. Coverage of all the cusps with

a thickness of no more than 2.53mm
is usually recommended. Glass ionomer
cement or flowable composite resin may be
placed over the root filling and in the pulp
chamber in order to achieve the required
thicknesses and internal form of the cavity
preparation. Ceramic onlay/crowns are
normally cemented with adhesive resins.
All ceramic crowns are not really suitable
in posterior teeth because of the risk of
fracture, although they are sometimes used
in premolars for aesthetic reasons.
There is no clear evidence to favour
ceramic or composite resin onlays/crowns,
but composite resin onlays/crowns are, in
general, less expensive and easier to repair
(Figure 5).

Figure 2. (a): Traumatised maxillary central incisors; (b and c): radiograph showing
crown fracture involving the pulp and root canal treatment was needed; (d and e):
ceramic veneer for UR1; and (f): direct composite restoration for UL1
331

Clinical
of endodontically treated teeth does not
allow for its application to all teeth. The
available evidences do not rule out the
use of cast posts; however, since the use
of cast posts may result in a significantly
greater loss of tooth structure compared
to fibre posts (Ikram et al, 2009), their use
should be limited to those cases in which
no additional dentine has to be removed
to allow for their cementation.

Length of posts
The length of the post classically assumed
to be ideal is when it reaches two-thirds the
length of the root (Figure6). Unfortunately,
most roots have curvatures that begin far
more coronally; therefore, this rule cannot
be applied in many cases. In conclusion, a
post that is longer than the clinical crown
of the tooth is advisable to limit the chance
of decementation and root fracture.

Ideal properties of post/cores

Metal-ceramic crowns
Cuspal coverage is required where tooth
structure loss is more than that associated
with an access cavity. Metalceramic
crowns are most extensively used for
restoring posterior teeth and as bridge
abutments. Unfortunately, a disadvantage
is that heavy tooth reduction is necessary
to create sufficient room for provision of
metal-ceramic crowns.

Posts

Indications for posts

In the restoration of endodontically treated
teeth, the placement of a post is generally
332 

suggested if the amount of residual tooth

structure is not sufficient to support a core
made of a plastic material (amalgam or
composite). The idea that the placement of
a post does not reinforce a tooth is indeed
very popular and remains debatable. The
placement of a fibre-reinforced composite
post would seem to protect against failure,
especially under conditions of extensive
coronal destruction; the most common
type of failure with fibre-reinforced
composite posts is debonding (Cagidiaco
et al, 2008).
The number of variables involved in
designing clinical studies on the restoration

The ferrule effect

A ferrule effect may be defined as the
envelopment of the tooth structure by a
crown. The ability to obtain a ferrule effect
is regarded as pivotal to the success of
any extracoronal restoration, irrelevant of
the core that has been placed. The ideal
extent of a ferrule remains contentious,
with the complete envelopment of at least
2.0mm of coronal tooth tissue regarded
as optimal (Tan et al, 2005). This should
provide adequate resistance to the lateral
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Figure 3. A broken down mandibular first molar. Following root canal treatment, the
tooth was restored using a fibre post and composite core followed by a zirconia crown

The ideal properties of post/cores include:

n Adequate compressive strength
n Strong enough to prevent flexion of the
core during parafunctional movement
n Resistance to leakage of oral fluids at the
core/tooth interface
n Ease of manipulation
n Ability to bond to the remaining tooth
structure.
Although not ideal, composite resins
have the majority of these properties and
are the material of choice as both post and
core materials. As a core build-up material,
composite resin may be bonded to the
remaining tooth structure using dentine
adhesives.

Clinical
forces imparted on the restored tooth.
Ideally, this ferrule should be continuous
around the entire circumference of the
tooth (Figure7).

Properties of fibre posts

Studies have shown that the mechanical
properties of carbon, glass and quartz
fibre posts are substantially similar; for
this reason, the more aesthetic glass and
quartz fibre posts have now replaced
carbon fibre posts (Mannocci et al, 2001).
The modulus of elasticity of fibre posts is
generally lower than that of metal posts but,
nonetheless, it is three to four times higher
than that of dentine (Tan et al, 2001). The
main difference, in terms of mechanical
properties between fibre and metal posts,
is the loss of flexural strength. As a result
of this, the mode of failure of fibre post
restored teeth is unlikely to be root fracture
but normally, decementation that may or
may not be associated with the development
of caries at the interface between the tooth
and the restoration. The adhesion of the
fibre posts to the composite core is mainly
micromechanical. The irregularities on the
surface of the post provide the retention for
the bonding resin.

Clinical and technical

aspects of fibre post
restorations
Tooth isolation
As with all clinical procedures that involve
adhesive dentistry, the use of the rubber
dam is preferred.

Removal of the gutta-percha

and canal enlargement

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This is easily carried out using GatesGlidden or Largo drills (Figure8a). Heated
instruments may also be used to remove
gutta-percha root filling.

Removing temporary
cement and sealer
remnants
The removal of temporary cement and any
sealer remnants is easily accomplished with
Dental Nursing June 2014 Vol 10 No 6

Figure 4. A mandibular first molar with occlusal root caries penetrating into the
pulp chamber. The tooth was restored with two separate composite resin fillings after
completion of the root canal treatment; this restoration will form an ideal core
should a crown be needed in the future. Radiograph following completion of
endodontic and restorative treatment is shown in the last image
the use of ultrasonic tips and preferably
aided by magnification with an operating
microscope (Figure8b).

purpose. Once the required size of post has

been selected, it is advisable to try the post
in the root canal (Figure8d).

Drying of the root canal

Bonding systems

The canal needs to be dried before the

application of the bonding system. Paper
points (Figure8c) or a controlled stream of
air from a Stropko irrigator (Vista Dental,
Racine, WI, USA) may be used for this

Both three-step bonding systems and

self-etching primers can be used for the
cementation of fibre posts as the bond
strength to root dentine achieved with
these two types of bonding agents is similar.
333

Clinical

Key points

The choice of restoration for an

endodontically treated tooth is
dependent on the amount of
coronal tooth tissue left.

The placement of a fibrereinforced composite post

would seem to protect
against failure, especially
under conditions of extensive
coronal destruction.

It is important to conserve a
ferrule of sound dentine to
increase the tooths resistance.

Insertion of composite resin

Composite resin cement

Conventional core or dual-cured
composite resins are also preferred for the
334 

cementation of the post. These materials

have mechanical properties closer to that
of dentine. Light-cured composite resins
are too thick to be inserted properly into
the root canal whereas flowable composite
and composite resin cements have a
much lower modulus of elasticity and
may, therefore, be the weakest part of the
restoration.

Insertion of the post

The post is simply inserted into the
root canal. There is no need to place
composite resin onto the post itself.

Composite resin core build-up

The composite resin core is created
immediately using the same self-curing
material. A light-cured composite resin
may also be used to complete the core
build-up (Figure 8g), following which,
crown preparation can be carried out at
the same visit.

Conclusion

A new approach to the restoration of

endodontically treated teeth has been
prompted by the introduction of fberreinforced composite (FRC) posts. The
survival of root-treated teeth has been
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The primer is applied on both the root

dentine and the post. It is advisable to use a
self or dual-curing resin. Microbrushes are
needed to ensure a uniform distribution
of the bonding agent into the depth of the
root canal (Figure8e).

Figure 5. Maxillary second premolar

and first molar requiring root canal
treatment. Preoperative and postoperative
radiographs. Since there is still a
considerable amount of residual tooth
structure left, both teeth were restored
with composite onlays. Radiograph after
completion of endodontic and restorative
treatment; the composite resin onlays
are radiolucent, hence not obvious
radiologically

To minimise void formation within the

composite resin in the canal, it should
be injected using a syringe with a special
tip specifically designed for this purpose.
The composite resin is injected into the
canal starting from the bottom of the
post space until it is completely filled.
Ultrasound transmitted via a tip
placed in contact with the syringe may
help ensure a more uniform distribution
of the composite resin into the root canal
(Figure8f).

Clinical

Figure 6. The lenght of the post ideally when it reaches 2/3 the length of the root

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Figure 7. The ideal ferrule should be

continuous around the tooth at least
2.0mm in width
assessed in several clinical studies.
Variables such as tooth type and
position within the dental arch in relation
to the occlusal forces, the presence of
proximal contacts, and the type of the
final restoration has been found to have
an effect on the longevity of root-treated
teeth. Additionally, the amount of coronal
residual structure has been recognised
as critical to the survival. In particular,
the contribution to increase mechanical
properties is to conserve a ferrule of
sound dentine to increase the tooths
resistance. The ferrule must be at least
2mm in width. 
DN
Cagidiaco MC, Goracci C, Garcia-Godoy F, Ferrari
M (2008) Clinical studies of fiber posts: a
literature review. Int J Prosthodont 21: 32836
Hansen EK, Asmussen E, Christansen NC (1990)

Dental Nursing June 2014 Vol 10 No 6

Figures 8af. The ideal ferrule should be continuous around the tooth at least 2.0mm
in width
In vivo fractures of endodontically treated
posterior teeth restored with amalgam. Endod
Dent Traumatol 6(2): 4955
Ikram OH, Patel S, Sauro S, Mannocci F (2009)
Micro-computed tomography of tooth
tissue volume changes following endodontic
procedures and post space preparation. Int
Endod J 42(12): 10716

Mannocci F1, Sherriff M, Watson TF (2001) Three

point bending test of fiber posts. J Endod 27(12):
75861
Tan PL1, Aquilino SA, Gratton DG et al (2005)
In vitro fracture resistance of endodontically
treated central incisors with varying ferrule
heights and configurations. J Prosthet Dent
93(4): 3316

335

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